HomeMy Public PortalAbout5750 ALESSANDRO AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby_aftirm that I have a certificate of consent to self
Insu,.i'cr a certificate of Workers'Compensation Insurance , or 76A642D
c certified copy.ihereof (Sec. 3800, Lab C.) CE 808(REV.8/81)
APPLICATION FOR PERMIT
Policy N-.99496 59C)Company F.ez Tnr]amni ter ®s
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
Certified copy is filed with t4 co/yf�ty building tion COUNTY OF LOS ANGELES BUILDING AND SAFETY
department. r
Date 6/24/92 Applicant M. Marrnna FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION �— , DEPTH
COMPENSATION INSURANCE - ADDRESS 5750 Alessandro
(This section need not be completed if the work involved by the LOCALITY Temple City, Ca MANHOLE REFERENCAy �^ L P E
permit is for one hundred dollars ($100)or less.)
NEAREST .TYPE,OF CONNECTION LENGTH FROM - --
I certify that in the performance of the work for which this CROSS ST. Y. CURB P.L. M.L.TO P.L.'
permit is issued, I shall not employ any person in any manner P.C.NO.-
so as to become subject to the Workers' Compensation Laws. OWNER John Georgino/.C.A. .Allison Dev. CO.IMP.NO. ,JOB NO.
MAIL TRUNK PERMIT NO. .ROAD PERMIT NO.
Date Applicant I ADDRESS 215 E. Las- Tunas Drive
- AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY San Gabriel TEL,NO. ' 287-9605
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATIONSIZE OF LOT NO.OF BLDGS. PERMIT NO.NOW ON LOT-
hereby affirm that I am licensed under provisions of Chapter USE OF
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTORFrank Marrone & Sons CONNECTION CHARGE FEE �.
License Number 397884 Lic.ClassADDRESS
9860 Lower Azusa Road REIMBURSEMENT FEE 0
t-'7 yti
�otg 1231 X92 DISTRICT NO. GROUP MAP PROCESSED BY
Contractor Marrone 8 SOn
CITYEl Monte TEL.NO. 444-2548
STATE LIC, ) 6
} ❑ I Om exempt Under Sec. Of the L.A.Co. LICENSE NO. .397884 CLASSC/36 �y1��} "�� B�. / '�� ` �y +� O
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL !L!G•rd �•� tuV
HOUSE SEWER CONNECTING TO �j DATE VALIDATION N
1, B. 8 P. Code for the following reason PUBLIC SEWER Z
+ SEPTIC TANK,SEEPAGE PIT OR FINAL
'PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY
,A - PRIVATE DISPOSAL SYSTEM
Signature �, o CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secton 7031.$, BUlsn ess and Pro- ALTER,REPAIR OR ABANDON HOUSE jaY ,(jE; •U' a at.i
fessions Code): - SEWER OR DISPOSAL SYSTEM - _
I ❑ I, as owner of the property, or my employees with wages as �( �(
^t�s
_1
their sole compensation, will do the work and the structure
is not-intended or offered for sale (Section 7044, Business A
and Professions Code). OWNERS Permit S Aa - rid .-I T
❑ 1, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEESO
licensed Contractors to construct the project (Section 7044, 1 HAVE AT-THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY Sar ^:.
1 hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ i 1 '^� '—R1 .
'OWNER OR- .. - .. .�..@.- _ _..I... ,...
for the performance of the work for which this permit is OWNERS AGENT_ 'C",1E CK __ o=;!
,issued (Sec. 3097, Civ. C.). }
k ADDRESS
(Lender's Name
Lender's Address
tl certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers, 1_ty '- (;I
and hereby authorize representatives of this County to enter -
uponn thea ove-mentione property for inspection purposes.
j Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE